I Chose Home Birth Because I Was Afraid of Dying in a Hospital—I Didn't Know It Would Save Me Money, Too
"It's not too bad," he said. "Our health insurance covers most of it." He explained that their midwife was in-network, so it would cost $3,500, and would be funded by the money they received at their wedding.
I still thought that was a lot to spend out of pocket. I'd already spoken to my insurance company about the costs of a hospital birth with my plan: my copay for in-network office visits and maternity hospital admission would total $25. I was curious to know why this friend, a nursing student, would choose to have a baby at home. She told me stories about her time observing in a labor and delivery unit, where she said doctors were often "a little too anxious to cut or use Pitocin to deliver babies before their shift ended"—which, she added, isn't necessarily a terrible thing. But it's "not always in the best interest of mom and baby," she explained.
Her perspective brought home the reality of being a woman—and in my case, a Black woman—facing our country's unacceptable rates of maternal mortality and unnecessary cesareans for births that would have been low-risk. According to the CDC, the maternal mortality rate was 17.4 per 100,000 live births in 2018—but for Black women, that rate was 37.3 deaths per 100,000, regardless of socioeconomic status. Between 2016 and 2018, Black women had more cesarean deliveries than women of any other race, and 17% more cesarean deliveries than white women. Those disparities are, in part, due to implicit bias in health care. Evidence shows that biases are likely to influence patient-provider interactions, health communication, and health outcomes.
Fearful of my potential birth experience in the traditional medical system, and desperate to feel in control of my health decisions, I decided to have a preconception consultation with a home birth midwife.
"Women should be empowered to create their own birth plans and birth experiences," she told me, "and they should be educated to be actively involved in decision-making and self-care for all aspects of their health." She believed that birth should unfold organically and without artificially imposed timetables and milestones. And it seemed to be working: Only 12% of her clients' planned home births resulted in a transfer to a hospital for any reason, and only 4% of all births were cesareans.
But then she let me know that, since her home birth services were out-of-network with my insurance company, I could be responsible for the majority of her $8,000 fee. I was torn; I wanted the freedom and support she was selling, and I wanted no part in the fear-mongering I'd heard about regarding hospital births. My midwife made me feel like I could trust that my mind and body were capable of safely bringing a baby into this world in my home, and I felt at ease with her—and her decades of expertise. By the end of our meeting, my husband and I were set on having a home birth. We had money saved, and we were comfortable taking the gamble that maybe, just maybe, insurance would cover it.
Two weeks later, my husband and I found out that we were expecting. The next day, I called the midwife. After offering congratulations, she suggested I contact my insurance company to find out how much of her fee they would cover. So I did, but the representative at my health insurance company couldn't give me a concrete number. He said that if I chose this midwife, my insurance plan's administration would let me know whether they would approve payment for her services—but only after she submitted an authorization request.
Halfway through my pregnancy, I received a letter from insurance stating they had approved the payment, but that I would be responsible for the in-network cost-share, which I assumed meant the aforementioned $25 copay.
At 32 weeks pregnant, my husband and I paid the midwife, with the expectation that insurance would cover it later and the midwife would reimburse us upon receiving that payment. We wrote a check for the entire $8,000 (rather than opting for a payment plan, which would incur non-reimbursable interest charges).
I delivered my son sunny-side up on my bedroom floor, after a six-hour labor including two hours of pushing—all with the gentle guidance of my midwife and her assistant. After my golden hour of bonding with my newborn, my midwife escorted me to the bathroom and stayed with me while I showered.
In August, I received an Explanation of Benefits letter from insurance stating that my plan would only cover $4,000. My midwife suggested I write my insurance's Member Appeals department to request they pay the billed amount, so I did, making it clear that the service authorization approval they'd sent indicated that I would not be responsible for any payments beyond my in-network copay.
Within three weeks, my midwife called to congratulate me: She had received the full $8,000 from insurance. She had attended hundreds of births, and mine was the first that a health insurance company had paid for in full. My midwife sent my reimbursement check, and I put it back into my savings account where it started.
When I got pregnant with my second child, I expected a similar experience. As before, I paid the midwife, anticipating reimbursement. Although by then COVID-19 was ravaging the country, I had another low-risk pregnancy and thus enjoyed telehealth visits from my dining room table. I gave birth to my daughter at home after a four-hour labor. The support we received from my midwife and her assistant—during birth as well as during the early weeks postpartum, when I was crying daily from dealing with hemorrhoids, breastfeeding problems, mom guilt and more—was invaluable.
I was surprised to get a call from my midwife's biller when I was about a month postpartum. A vendor had reached out to her on behalf of my insurance company, attempting to negotiate a reduction in payment to the midwife who had been so essential to me. I had to decide whether to accept the offer and be responsible for the balance, or to reject it, in hopes of a better payout. The gambler in me wanted to reject the offer, but the biller warned me that insurance could return with a lower number if I didn't accept. My husband and I deliberated, and hesitantly rejected the offer.
The biller contacted me again with a higher figure, which I also rejected. Then I received an Explanation of Benefits letter from insurance stating they'd only pay $4,073, which was less than either of their vendor's offers had been. Emboldened to continue playing their game, the next day, I mailed a letter requesting additional payment, and a couple weeks later, an insurance representative notified me that the claim was settled—they would pay.
My midwife received her compensation, reimbursed me, and asked for my advice—so that she could help her other patients save money, too. Here's how to work with your insurance to cover home birth midwife services.
Ask if you have in-network home birth midwives
If there are none, find out if you need a prior authorization for your out-of-network midwife, and make sure your midwife submits the authorization request. If the request is denied...
Don't be afraid to appeal
Ask your insurance company how you can appeal the decision. Then, follow their instructions. If you get denied again, ask your insurance company for the next step you can take to get this service approved. Repeat as needed, if you're willing. When you do get approved authorization for your midwife:
Have your midwife bill your insurance post-birth
If your insurance company tries to negotiate payment, reject all offers that you are not comfortable with. Accepting an offer could mean forfeiting your rights for an appeal later.
Yes, you can appeal again.
When you get your Explanation of Benefits statement from the insurance company indicating how much they have decided to pay, follow their instructions for appealing the decision. In your appeal, include what your authorization letter said that led you to believe that you would not be responsible for payments beyond your in-network cost-share. Tell them that your midwife is charging you the balance if they don't pay; focus on the facts of your case only. Escalate the case with your insurance company, and potentially with a third-party reviewer, until your case is settled.
For me, I didn't view my insurance company as a villain. After all, it's their job to negotiate lower payments to service providers. My midwife explained to me that when it comes to home birth, insurance providers aren't familiar with codes for what you're billing—since the birthing facility is essentially being brought into your home. Midwives may see their patients for an hour every appointment, not the 15 minutes that an OB-GYN might, which can mean an insurance provider doesn't understand that a dollar amount, of, say $8.000 is actually fair and reasonable compensation.
Remember: You have a right to fight, to advocate for yourself and your baby. Not only can it help you save money, but it sets a standard for what's of value in the birth process.
While I know that home births are not for everyone, I had beautiful experiences with both of my pregnancies. My midwives empowered me to make my own educated decisions. Their services would have been worth the cost had I been responsible to pay $25, $4,000 per birth, or even the full amount out of pocket.
While I'm amazed that I convinced my insurance company to pay $16,000 for my home births, I am disappointed that I had to be my own advocate—and that most people don't bother to do themselves the same favor. This lack of advocacy and involvement leads to far too many people either dismissing home births as inaccessible or paying for them with money they could have saved for their new lives as parents. Every pregnant person deserves to have a birth that makes them feel safe, respected, and supported, without fearing for their life—or how they're going to pay to save it.